At the heart of the controversy about how to meet the needs of young people questioning their gender has been the huge rise in referrals to the Tavistock – previously the only dedicated clinic in England and Wales treating children with gender dysphoria.
The clinic was closed one month before the Cass review into youth gender identity services, commissioned by NHS England and led by the British paediatrician Hilary Cass, which found that children had been “let down” by the NHS amid a “toxic” public discourse.
Her report recommended a significant shift in treatment away from medical intervention towards a more holistic approach to care, including therapy and treatment for coexisting mental ill health, neurodivergence or family issues, and to be provided by a network of regional hubs rather than concentrated in one location.
The Cass effect
Fourteen months later and the exponential rise in referrals for NHS care has halted, with figures showing a sharp reduction from up to 280 referrals a month at the Tavistock to between 20 and 30 a month this year, a 10th of the earlier rate.
James Palmer, the medical director for specialised services at NHS England, who is responsible for implementing the recommendations of Cass, suggests a number of factors are behind the decrease. Young people can now only be referred for the youth gender service through mental health or paediatric specialists, rather than by a GP.
Palmer also believes the reduction is partly because of the “change in philosophy” brought in by Cass about hormone treatments. Her review concluded there was “remarkably weak evidence” that puberty blockers (prescribed to give young people experiencing distress and dysphoria about their bodies time to consider their next move) and cross-sex hormones (which masculinise or feminise people’s appearances) improve young people’s wellbeing and there was concern they may harm health.
Cass prompted a temporary ban on the use of puberty-blocking drugs, which was extended indefinitely by the health secretary, Wes Streeting, last December. Cross-sex hormones may be prescribed to 16- to 18-year-olds in rare cases but in practice none have been since the review.
“There’s also an impact – completely immeasurable – of the change in stance in this country and around the world,” Palmer adds. The Cass review was clear, he argues, that even social transition is “not a neutral act” and better information is needed about the outcomes for children who do so, as well as support for parents and schools. “But there is also an impact from the global political environment which has become less accepting of trans people and gender-questioning young people.”
Palmer, a neurosurgeon by background, says waiting times for the new hubs are “still really significant” and that it will take up to three years to work through the “substantial backlog” inherited from the Tavistock, and services are continuing to face heavy criticism from young people and their parents.
According to NHS England the waiting list for the new hubs peaked in December 2024 at more than 6,400, and has been reduced to just over 6,000. There are now three regional centres open in London, Bristol and north-west England, with the capacity to see about 25 patients a month, and a fourth is expected to open in the east of England this year.
Once all seven regional hubs have opened, Palmer says “we will get to where we want, which is that individuals, as soon as that [gender] incongruence starts to be truly persistent, even at a young age, will be able to get access to an NHS service”.
While opinion still differs on how best to meet the needs of this vulnerable group of young people, critics of what Palmer describes as a “change in philosophy” argue that the fall in referrals to NHS services masks the true numbers seeking intervention, with many families turning to private providers and the hidden economy to access drugs to help them live as a different gender.
Palmer accepts the long waits for help “affect how individuals approach their care and, of course, some take desperate steps to go to unregulated providers and seek hormones”.
A clinical trial of puberty blockers, which was recommended by Cass, is being set up by an independent research team at King’s College London, which is taking it through ethical and regulatory approvals.
An expert panel will report to Streeting in July after considering a similar ban on cross-sex hormones for 16- to 18-year-olds, with initial signals that further restriction is likely.
Long waits and legal challenges
The Guardian spoke to a range of parents about their concerns over their children’s treatment since the Cass report was published.
Some said they felt more hopeful since Cass’s emphasis on evidence-based care, and were pleased to see underlying issues highlighted in her report – such as bullying, neurodiversity, emerging same-sex attraction and trauma – being addressed first in regular sessions with a psychologist.
Others said this culture change had not reached adult services, where older teenagers were being treated, adding they were the same cohort subjected to the same societal factors that were reviewed by Cass.
Some parents were particularly frustrated that other European countries had conducted similar reviews of the evidence base for hormone treatments but came to different conclusions that supported their use for young people.
They also worried that staff at the new hubs did not appear to be very experienced in gender care, with what they felt was limited understanding of how time-critical decisions about hormone treatment can be. Pathways to gender-affirming hormones, for example, although technically still available were simply not discussed.
One family reported that they were warned at a hub that accessing hormone treatment privately could trigger a safeguarding referral by their GP and even a police report.
Another said it was unfair that NHS England had moved 200 young people already receiving puberty blocking or gender-affirming treatment at the Tavistock to a Nottingham clinic where their hormone treatment was continuing, while other youngsters were not offered that option.
For 18-year-old Ben, who lives in the Midlands with his family and is about to start a degree at a Russell Group university, there is “definitely value” in holistic support, as prioritised by Cass. But he says talking therapies lose their value if young people feel they are having to “prove themselves” deserving of access to hormones.
Ben joined the youth services waiting list at the age of 14, but was transferred to the adult NHS waiting list earlier this year after he turned 18, never having had an appointment. Instead his family accessed puberty blockers and then testosterone from an online clinic.
“I can understand that for someone who has not been in my position this is obviously a massive decision for a young person to make, and it is necessary to have safeguards in place, but to completely remove access to hormones is going to have a negative impact on many young people for the rest of their lives.
“Whilst using unregulated private providers has more risks than accessing healthcare through the NHS, risk is much greater where young trans people are left without any access to healthcare at all, as is the case for many who are unable to pay for private healthcare.”
Some young people formerly treated at the new hubs have found their way to the private Gender Plus, a clinic that treats young people as well as adults, and is the only service in the UK able to prescribe cross-sex hormones to 16- to 18-year-olds, in line with NHS England guidance through its Care Quality Commission-registered hormone clinic.
Its director, Dr Aidan Kelly, said: “I’m hearing there’s a huge drop-out rate [from the new hubs], which doesn’t surprise me because the evidence base for group therapy helping young people with gender dysphoria is weaker than that for hormone interventions. They feel that the NHS has given up on them and so they are just waiting to age up into the adult service.”
The adult service is under review by NHS England, in response to detailed concerns raised by Cass following her youth review, including “out of control” waiting lists, inadequate consent processes, and limited explanation of the risks involved in treatment.
In 2024, Gender Plus’s first full year, it took 874 referrals, 343 of whom were under 18, and it has expanded to sites in London, Birmingham, Leeds and Dublin, with 20 staff, many of whom formerly worked at NHS gender services. Of those aged 16 to 18, 61% were prescribed gender-affirming hormones after completing an average six months of assessment.
Gender Plus is facing a judicial review at the end of June, brought by the former NHS gender specialist Sue Evans, who also instigated proceedings against the Tavistock in 2019, challenging the CQC’s decision to grant registration to the Gender Plus hormone clinic in January 2024, and the subsequent decision to award the clinic an outstanding rating in December 2024 after its first inspection.
Kelly suggests NHS England is assuming by denying young people access to medical pathways, they “will simply give up”.
“There’s no evidence of that happening and in fact there is evidence that it does harm.”
Last year, the Guardian reported on experts warning that growing numbers of under-18s were turning to the medicines hidden economy. Some of those young people are becoming politically active. In March, the activist group Trans Kids Deserve Better disrupted a Guardian event with Streeting, highlighting that he had not consulted with trans youth before making decisions about their treatment but had spoken to other groups that oppose gender-affirming care.
NHS England says that the more cautious approach approved by Cass includes regular appointments with a clinician, and a suite of therapy options, one to one, in groups and with family, as well as treatment for coexisting mental health issues, including medication if necessary.
In building the new services, efforts have been made to let clinicians get on with their day job away from the media spotlight. But Palmer says he worries that “the polarised debate in the newspapers” does not recognise there are many young people “who are really impacted by the dysphoria and distress that can follow gender incongruence and need access to the care of an NHS service”.